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Hoarding Disorder: Phenomenology

and Treatment

MARLA W. DEIBLER, PSY.D. Executive Director, Licensed Clinical Psychologist

The Center for Emotional Health of Greater Philadelphia Cherry Hill & Princeton, NJ

DSM-5: Obsessive Compulsive and Related Disorders

•Obsessive Compulsive Disorder

•Body Dysmorphic Disorder

•Trichotillomania (Hair Pulling Disorder)

•Excoriation (Skin Picking) Disorder

•Hoarding Disorder

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Hoarding Disorder (DSM-5)

•Persistent difficulty discarding or parting with possessions

•Perceived need to save items, distress associated with discarding

•Symptoms result in the accumulation of a large number of possessions that clutter living areas & compromise their intended

use

•The symptoms cause clinically significant distress

•The hoarding symptoms are not due to a general medical condition

• The hoarding symptoms are not better accounted for by another mental disorder

Phenomenology

•Prevalence

•No good prevalence data to date

•Estimated at 2% to 5% of the population

•Conservative estimates show 3 million Americans are affected

•Estimates note that rates may be as high as 1 in 20 people

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Phenomenology

•Average age - 50 years

•Education - varies

•Marital status - tend to be single

•Residence - tend to reside alone

•Family history of hoarding is common

•50-85% of hoarders report 1st degree relative who is a “packrat”

•Some live in squalor, but these conditions are less prevalent than cluttered/disorganized homes and are uncommon among those who seek treatment

Clinical Course

•Average age of prodromal onset – 13 years

•68% onset before 20 years of age

•Little evidence for history of material deprivation

• Hoarding may develop or be exacerbated by a stressor, trauma, loss, or life transition

•Course – chronic, progressive

•Insight – varies, fluctuates, but frequently poor

•Severity - varies

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Co-occurring Disorders

•Depression (60%)

•Social phobia (30%)

•Generalized anxiety disorder (25%)

•Obsessive compulsive disorder (15-17%)

•Attention deficit hyperactivity disorder

•Personality features

•Anxious/avoidant, dependent, paranoid/schizotypal

•Many report executive functioning concerns

Etiology

•Genetic Factors – twin studies (Ivanov et al.,2017)

•Specific genetic abnormalities (Samuels et al, 2005,2007)

•L/L genotype of COMT Val158Met polymorphism

•Chromosome 14

•Modeling, Traits

•Familial indecisiveness

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Assessment: Behavior & Psychological Functioning

•Comprehensive clinical interview

•Consider consulting with family

•Comprehensive behavioral assessment

•Assess all aspects of the behavior

•Assess antecedents, the behavior itself, and consequences

•Assess behavior reinforcement and any replacement behaviors

•Assess what function hoarding is serving

•Explore how the individual might meet that need with more adaptive behaviors

•Assess current activities of daily living

•Assess interpersonal impact

Assessment

•Hoarding Interview (Frost & Steketee, 2007)

•Structured Interview for Hoarding Disorder (SIHD) (Pertusa et al, 2013)

•Saving Inventory-Revised (SI-R) (Frost et al., 2004)

•23 self-report items, 2 subscales (acquisition, discarding, clutter)

•Children’s Saving Inventory (Storch et al., 2011)]

•Hoarding Rating Scale (Tolin et al, 2010)

•Clutter Image Rating Scale (Frost & Steketee)

• In older patients, in particular, additionally assess for:

• Depression and Anxiety

• Cognitive functioning

• Functional impairment

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Assessment: Interpersonal Difficulties

•Romantic relationships

•Friendships

•Social Isolation

•Family conflict

•Legal and financial difficulties

•Problems with housing

•Problems with social service agencies

Assessment: Activities of Daily Living

•To what extent does clutter prevent:

•Preparing food, using refrigerator, using stove

•Accessing closets and exits, bed and bathroom

•Living Conditions

•Insects, rodents

•Rotten or contaminated food

•Urine, feces, etc.

•Safety Issues, Fire hazards

•Blocked windows, entrances, and stairways

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Conceptual Model of Hoarding Disorder

•Core Beliefs and Vulnerabilities

•Information Processing Deficits

•Excessive Emotional Attachments

•Erroneous Beliefs about Self and Possessions

•Emotional Reactions

•Positive & Negative Reinforcement and Avoidance

(Frost & Steketee)

Information Processing

•Attention, distractibility

•Categorization, organization

•Decision making and general indecisiveness

•Under-inclusive categories

•Uniqueness

•Churning

•Determining relative importance

•Value system: Instrumental, Sentimental, Intrinsic

•Visibility, touch, and perceived importance

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Emotional Attachment

•Anthropomorphism

•Sentiment

•Possessions as representations of others

•Exaggerated loss

•Possessions as part of themselves

•Enhancing the self

•Comfort and discomfort

•Both positive and negative emotional consequences to the behavior which serve to reinforce the pattern

Erroneous Beliefs: Perfectionism

•Perfectionism

•Most common belief (80%)

•Fear of making a mistake

•Fear of not organizing an item perfectly

•Fear of not purchasing an item and not being able to acquire the item at a later date

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Erroneous Beliefs: Memory

•Memory

•Concerns for forgetfulness, memory impairment

•List making

•Visual reminders

•Need to recall all information

•Saving written items

Erroneous Beliefs: Opportunities

•Possessions provide opportunities

•Overestimation of importance or value of items

•Everything has a purpose or use

•Creativity

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Erroneous Beliefs: Responsibility and Control

•Need for preparedness

•Personal responsibility

•Moral responsibility

•Fear of being wasteful

•Beauty / Aesthetics

•Identity and sense of self

•Possessions as a source of safety, comfort, and control

•Need for control over possessions

Reinforcement and Avoidance

•Acquisition satisfaction positive reinforcement

•Avoidance negative reinforcement

•Factors in avoidance behaviors:

•Information processing deficits

•Erroneous beliefs

•Emotional processing difficulties

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Example : Miranda and Toys

•Core Beliefs

•I must be a good mother.

•Good mothers provide for their children.

•Vulnerabilities

•Pregnancy Complications, impaired mobility, anxiety •Attachments and Beliefs

•Sentimental, Instrumental, Personal Responsibility

•Buying toys represents being a good mother

•Emotional Reactions

•Anxiety, Guilt, Excitement

•Positive Reinforcement: pride and satisfaction

•Negative Reinforcement: relief from anxiety and guilt

Pharmacotherapy and Combination Therapy

•Data is limited on pharmacotherapy; No FDA-approved medication

•No evidence of significant treatment response for combination

•Response rate to paroxetine and E/RP -> 18% for hoarding vs. 67% for OCD

•Response rate to multiple medications and CBT in partial hospitalization program for hoarding -> 45% for hoarding vs. 63% for OCD

(Black et al., 1999; Saxena et al., 2002)

• A systemic review of 20 treatment studies concluded modest, yet statistically significant improvement with most treatments, but remaining in the clinical range post treatment.

(Thompson et al., 2017)

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Hoarding-Specific Cognitive Behavioral Therapy

•Behavioral assessment

•Psychoeducation and case formulation

•Motivational enhancement (MI or ACT, as needed)

•Skills training (organizing, problem-solving, decision making)

•Evaluate thoughts and beliefs

•*Exposure and response prevention:

•Non-acquiring

•Excavation

•Discarding

(Steketee & Frost 2007)

Motivational Interviewing

•Working with limited insight and ambivalence

•Articulate ambivalence

•Cost - benefit analysis of change

•Foundational principles for motivating change:

•Express Empathy

•Develop Discrepancy

•Work with discrepancy between behavior and beliefs/goals

•Avoid Argumentation

•Roll with Resistance

•Empathize but pose questions that encourage problem-solving

•Support Self-Efficacy (Miller and Rollnick)

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Values-Based Motivational Enhancement

•Identify personal values

•What does the patient value most in his or her life?

•How does hoarding fit in with the things you value in life?

•Identify personal goals

•What does the patient most want to do in his or her life?

•Does the hoarding behavior or the condition of the home prevent him or her from doing these things?

•Can you still experience distress while, at the same time, moving toward what is important to you?

•Referring to the patient’s self-identified values and goals throughout treatment can help to address ambivalence and increase motivation

Skills Training

•Emotional processing and coping

•Cognitive processing and decision making

•Development of rules for keeping/discarding

•Increasing insight into cognitive distortions

•Improving cognitive restructuring and/or psychological flexibility

•Organizational strategies

•Planning, categorizing, disposition, structure of systems

•Problem solving

•Define, brainstorm, select, try, evaluate)

•Cognitive flexibility (evaluating and shifting)

•Interpersonal communication and effectiveness

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Evaluating Thoughts and Beliefs – Addressing Cognitions

•Socratic questioning, downward arrow technique

•Cost-benefit analyses

•Perspective taking

•Behavioral experiments

•Identify maladaptive beliefs regarding self & others

•Challenge erroneous beliefs

•Identify cognitive distortions & cognitive restructuring

•Replace maladaptive thoughts that contribute to the behavior with more adaptive/accurate thought and/or teach distress tolerance

•Alternatively, increase cognitive flexibility by means of ACT in combination with behavioral experiments and ERP

Anxiety, Avoidance, & Maladaptive Coping

Anxiety

Time

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Facilitating New Learning Through Exposure and Habituation

Anxiety

Time

Exposure and Response Prevention

•The part of treatment most talked about

•Non-acquiring and excavation

•By strategically planning excavation exposure, clients will be exposed to triggers throughout the process and have the opportunity to use newly learned skills to facilitate adaptive behavior patterns

•Develop relevant hierarchy, teach SUDS

•Establish rules for use during exposure

•Emphasize importance of practice and homework

•Review what is learned from exposure exercise following each exposure

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Establish Treatment Rules

•Do not touch possessions unless there is explicit permission

•Establish rules for acquiring, keeping, and discarding

•Establish locations for items during categorization/sorting

•Establish categories first, then sort

•Develop action plan for discarding items

•All decisions must be made by the individual

•O.H.I.O.

•Proceed systematically

•Help clients maintain focus

•Help clients create structure plan for excavation

Resources

• www.hoarding.iocdf.org

• www.childrenofhoarders.com

• “Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding” by David Tolin & Randy Frost. Oxford University Press, 2007.

• “Stuff: Compulsive Hoarding and the Meaning of Things” by Randy Frost & Gail Steketee. Houghton Mifflin Harcourt, 2010.

• “Compulsive Hoarding and Acquiring: Workbook” and “Compulsive Hoarding and Acquiring: Therapist Guide” by Gail Steketee & Randy Frost. Oxford University Press, 2006.

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Questions?

MARLA W. DEIBLER, PSY.D. Executive Director, Licensed Clinical Psychologist

The Center for Emotional Health of Greater Philadelphia Cherry Hill & Princeton, NJ